USICH Blog

Archive

To accompany the release of Opening Doors, as amended in 2015, we will be taking a closer look at each of the four key updates to the document this week. We’ll be sharing comments from partners, community members, and the USICH staff on how the updates are impacting their daily work, helping to prevent and end homelessness across America, as well as highlight the key changes around the updated topic.

Spotlight on Medicaid

"When launched in 2010, Opening Doors was more than a blueprint for effective Federal, state and local partnerships to end homelessness, it motivated all of us - inside and outside of government - to work harder, together, to address the needs of our most vulnerable people. Five years later, it is just as impactful; a platform on which proven solutions such as supportive housing can expand, and an affirmation that services through Medicaid, coordinated assessment and access, and cooperation among systems must grow too if we are to succeed and tackle homelessness once and for all." –Deb DeSantis, President/CEO, Corporation for Supportive Housing

The Affordable Care Act creates new opportunities to leverage Medicaid to end homelessness, specifically by financing services that can help people obtain and maintain housing as well as achieve health and well-being. All states now have the opportunity to expand Medicaid eligibility to nearly all individuals under the age of 65 with incomes up to 133 percent of the Federal poverty level. As of May 2015, 30 states including the District of Columbia have acted to expand Medicaid programs, and provide health coverage to millions of adults without dependent children for the first time. More than 16 million Americans have gained health coverage, bringing the number of people without insurance down to historic lows. Included in the newly insured are approximately six million of the lowest income Americans, who have gained access to public health insurance through Medicaid and the Children’s Health Insurance Program (CHIP). And while the data is limited on the specific number of people experiencing homelessness who have gained coverage, we have numerous reports that enrollment in Medicaid and other types of health insurance among people experiencing homelessness has grown significantly.

This blog was originally published on the Bill and Melinda Gates Foundation blog, Impatient Optimists.

By David Wertheimer

Twenty-five years ago, in the earlier years of the AIDS epidemic, health care and housing providers figured out that without housing, the health of people living with AIDS deteriorated far more rapidly than for those who had stable homes. AIDS Housing of Washington, now Building Changes, helped coin a critically important phrase that became a game changer in the fight against AIDS: “Housing is healthcare.”

A quarter century later the phrase still rings true, and has expanded meaning in the challenging work of ending homelessness for all people, including families, single adults, youth, and veterans.

The Bill & Melinda Gates Foundation recently hosted more than 100 state and local leaders in ending family homelessness together with health care leaders responsible for implementing the Affordable Care Act (ACA) and Medicaid expansion here in Washington State. As the health care system changes, the opportunities to integrate and improve the delivery of both housing and health services to families recovering from homelessness have the potential to be transformational.

What might this look like in practice? We can now envision and realize the possibilities, thanks to a 5-year, $65 million competitive federal grant for State Innovations in Medicaid secured by the Washington State Health Care Authority. In part, this grant offers the opportunity to think in new and innovative ways about “social determinants of health,” the broad set of conditions in which we live and work, at home and with our families, including the air we breathe and the water we drink, that play a more important role in promoting long-term health than medical interventions.

Five years since the passage of the Affordable Care Act, many of the major objectives of the law are being met; more than 16 million Americans have gained health coverage, bringing the number of people without insurance down to historic lows. Included in the newly insured are approximately six million of the lowest income Americans, who have gained access to public health insurance through Medicaid and the Children’s Health Insurance Program (CHIP). And while the data is limited on the specific number of people experiencing homelessness who have gained coverage, we have numerous reports that enrollment in Medicaid and other types of health insurance among people experiencing homelessness has grown significantly. With so many people now able to access health care coverage, the results are in: the Affordable Care Act is working.

Of course, increasing access to health coverage is only one objective of the law. The other major objective is to shift the focus of health care away from procedures and treatments and towards the overall quality of care and people’s health outcomes. For people who experience homelessness, we know that having stable housing is essential to health. Stable housing not only has direct benefits on health—reducing exposure to high-risk behaviors and the negative effects of life on the streets—but it also creates a platform for better care. Thus, for people experiencing homelessness, the ultimate measure of whether or not the Affordable Care Act is working may be the degree to which it can incentivize the health care system to address housing needs as a foundation for better health.

It has been proven time and time again that for people experiencing chronic homelessness and suffering from chronic health conditions, the path to improved health begins with stable housing, namely through supportive housing. Supportive housing (also known as ‘permanent supportive housing’) has been shown to improve physical and behavioral health outcomes for people experiencing chronic homelessness, while simultaneously lowering health care costs by decreasing emergency room visits and hospitalizations. In most communities today however, the services that make supportive housing so effective are still funded by a patchwork of public and private sources, or in some cases, are severely under-funded. Fortunately, thanks to the Affordable Care Act we now have the potential to create a more systematic and sustainable way to finance services in supportive housing -- through Medicaid.

The truth is, this isn’t all new. Medicaid has covered these types of supportive housing services for a long time. After all, one of Medicaid’s first authorities allowed states to cover primary care case management. What is new is the Affordable Care Act, which by increasing the coverage of people experiencing homelessness under Medicaid and by shifting the focus of health care on value rather than volume, creates new opportunities to increase the role of Medicaid in covering services in supportive housing. At the same time, Medicaid is a Federal and state program and the decision to cover these services under Medicaid rests with the states. Whether states do so will depend on the degree to which they are made aware of the cost-benefit of helping people access and obtain housing as opposed to cycle in and out of emergency rooms, inpatient hospital beds, shelters, and the streets.

We all have the responsibility of educating states about the cost-effectiveness of supportive housing and the opportunity to cover services in supportive housing under Medicaid. Here are four things you can do to ensure your state includes these services:

Whether as a result of a health or economic crisis or fleeing domestic violence, the experience of homelessness is extremely traumatizing for families generally, and can be especially traumatizing for children. We know that there is not a one-size-fits-all solution for every family experiencing a housing crisis. Connecting families to housing interventions and services that are appropriate to their specific needs is an essential part of the actions we identified as critical to meeting the goal of ending homelessness.

This week CSH, in partnership with the Washington Low Income Housing Alliance, published Creating a Medicaid Supportive Housing Services Benefit. In the white paper CSH lays out an easy-to-follow framework for states that want to create a Medicaid benefit to pay for the services in supportive housing. The framework consists of five action steps: 1) Determine benefit eligibility criteria; 2) Define the package of services to be delivered; 3) Align the state Medicaid plan; 4) Establish a financing and reinvestment strategy; and 5) Operationalize the benefit.

President Obama has requested an increase of $301 million in HUD’s Homeless Assistance Grants. At a time of budgetary and fiscal challenges, $301 million sounds like a lot of money. In my view, it’s a small price to pay to achieve an end to chronic homelessness and save the lives of roughly 100,000 people. It’s especially small when compared to the cost of doing nothing, not only in terms of human lives, but also in real taxpayer dollars.

The expansion of Medicaid coverage under the Affordable Care Act (ACA) will mean that millions of currently uninsured adults will be eligible for coverage, including many formerly homeless individuals residing in supportive housing.

Many states are still opting out or remain undecided about whether to participate in Medicaid expansion. One factor these states might consider in evaluating or re-evaluating their decision to participate is the impact of Medicaid expansion on homelessness in their state. But the benefits don’t stop there. State budgets, hospitals, health care providers, and Americans in general also stand to gain from Medicaid expansion.

Not long ago, I sat in the same place that you are sitting, managing the Continuum of Care and leading our community's ten-year plan to end homelessness. You have challenging jobs to do and I know you are balancing many competing issues and priorities. I've been fortunate to visit communities that are making great progress, and to support and work with communities that still struggle. Now I would like to share some reflections on the lessons I've learned from you, my colleagues, in our mission to end homelessness. Thank you for listening and especially for acting.

Today I want to address chronic homelessness, which is the first goal in Opening Doors. We have fewer than 1,000 days to bring the number of people experiencing chronic homelessness to zero; every day and every minute counts. For people living with disabilities and disabling conditions, every day or minute spent on the streets is another day or minute spent struggling to survive. So this message is a call to action. I am reaching out to ask, are we doing everything we can do to end chronic homelessness by 2015? Here are the top-ten questions you and the leaders of your ten-year plan should consider (not likely to be picked up by David Letterman but hopefully useful nonetheless).

Starting in 2014, the Affordable Care Act allows states to expand Medicaid to most people earning at or below 133% of the federal poverty level (FPL), which is about $14,856 a year for an individual and $25,390 for a family of three in 2012. (To their credit, some states have gone ahead and expanded early.) This provision helps unify the current “categories” of Medicaid, where very low income children, pregnant women, adults who can prove a permanent disability, and parents in some states are eligible for Medicaid, but those without a proven disability or dependent children are not—creating a significant disparity in access to care among those at the lowest income levels. A recent Urban Institute analysis found 15 million uninsured adults will now be eligible for Medicaid, which would allow them access to the health care services needed in order to treat and manage chronic illnesses, prevent new health conditions from developing, and protect against financial ruin due to inability to pay medical bills.

What We're Talking About is a weekly column from USICH Communications on the topics and issues in the news and on our minds. Topics range from international and national conferences, news from around the country, innovative work to highlight, and more. We look forward to catching you up news you may have missed and connect you to articles and resources.

USICH released a general newsletter this week which compiled news from federal agencies, national partners, and cities revamping their approach to homelessness. If you missed it, you can check it out here.

A Reminder of the Needs of Veterans Two Years After End of Combat Operations in Iraq

Today marks the two year anniversary of combat missions in Iraq, a milestone to be sure, but one that must remind the country of the needs of Veterans of that conflict as well as Veterans of previous wars. In Yuma, Arizona, the allocation of the city’s first HUD-VASH vouchers will enable Veterans in that community to have stable housing and access to coordinated supportive services for their recovery. The HUD-VASH program continues to expand to both more communities and to more Veterans because of its ability to stabilize vulnerable Veterans in the long-term.

I spent August 8, 9, and 10 in Louisiana with Don Moulds, the Acting Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services. Don is also Secretary Sebelius’ point person for USICH. We went to talk with people operating and overseeing the Louisiana Permanent Supportive Housing project. For those who aren’t familiar with this incredible project, you can find more information from the Corporation for Supportive Housing, which highlighted this state-wide project as part of their Focus on Health Care Series in February 2012. If you don’t have time to listen to the webinar now, here’s the short version: after the hurricanes in 2005 and 2006, the state, advocates, and community providers worked together to figure out how to help people with one-time federal recovery investments. What has emerged is a unique model to use these new resources for housing and supportive services to provide permanent supportive housing across the region. Federal investments included Community Development Block Grant funds, Shelter Plus Care and Section 8 Housing Choice Vouchers.